Failure to Maintain Resident Dignity by Not Covering Urinary Collection Bag
Penalty
Summary
A deficiency occurred when staff failed to maintain a resident's dignity by not ensuring the resident's urinary collection bag was covered with a privacy bag. The resident, who had multiple diagnoses including multiple sclerosis, bladder cancer, and acute pyelonephritis, required maximum assistance for daily activities and had a urinary catheter or urinary ostomy. During an observation, the urinary collection bag was found hanging on a bedside drawer handle without a dignity cover. Staff interviews confirmed that the cover had been removed during care and was not replaced, and that staff were aware the bag should be covered for privacy. The facility's policy required that urinary catheter bags be covered to promote resident dignity and self-esteem. Multiple staff members, including a CNA, LVN, and the DON, acknowledged that the urinary collection bag should have been covered and that its absence could affect the resident's psychosocial wellbeing. The failure to provide the dignity cover was confirmed through observation, staff interviews, and review of facility policy.
Plan Of Correction
Residents rights/Exercise of Rights How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: CNA 1, on 04/30/2025, immediately placed a dignity bag on Resident 1's urinary collection bag. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Infection Control Nurse, on 4/30/25, completed a facility audit of all residents with foley catheter with dignity bag and found no other deficiencies noted. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: DON performed one-to-one in-service on 4/30/25 to CNA 1 and LVN 1 regarding placement of dignity bag to cover resident urine collection bag; and facility policy and procedures for Dignity and Infection Control. DON performed licensed staff in-service to LVN's and RN's on 4/30/25, 5/1/25, and 5/2/25 regarding placement of dignity bag over residents' urine collection bags as well as the facility policies for Infection Control and Dignity. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Managers and staff will perform facility room rounds using the facility tool entitled "Resident Centered Care Room Rounds Report" Monday to Friday to verify all foley catheters' urine collection bags have a dignity bag in place. On weekends, the Manager of the Day or designee will perform these room rounds to verify all appropriate dignity bags are in place. The Director of Nursing will collect and review room rounds data weekly and will report audit findings to the Quality Assurance Committee monthly for three months for review and evaluation. The Director of Nursing and/or Administrator will determine if continued auditing and monitoring are recommended after three months. Completion Date 5/22/25 F 550 F 550 Develop/Implement Comprehensive Care Plan